Fillable Instructions for Reinstating New Jersey Ofce of the (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Instructions for Reinstating New Jersey Ofce of the (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Orthotics and Prosthetics Board of Examiners
124 Halsey Street, 6th Floor, P.O. Box 45034
Newark, New Jersey 07101
(973) 504-6445
Instructions for Reinstating
In accordance with the Uniform Enforcement Act, a professional or occupational license may be reinstated,
provided that the applicant qualies for licensure, and complies with all applicable provisions of N.J.S.A.
45:1-7.4. The necessary application and materials for applying for reinstatement are enclosed.
1. Complete: The enclosed application for reinstatement. attached to the documentation/fees listed below.
2. Submit the following documentation and fees accordingly to your category:
• Biennial Renewal Period (2017-2019):
• Orthotics, Prosthetists, Prosthetist-Orthotist - $410.00
• Orthotist Assistant, Prosthetist Assistant, Prosthetist-Orthotist Assistant - $210.00
• Biennial Renewal Period (2015-2017) if expired in 2015:
• Orthotics, Prosthetists, Prosthetist-Orthotist - $410.00
• Orthotist Assistant, Prosthetist Assistant, Prosthetist-Orthotist Assistant - $210.00
• Reinstatement Fee: $150.00
• Criminal History Background Check Fee: $ 17.50
All three payments must be separate check or money order. Cannot be combined on one
payment. Must be made payable to State of New Jersey.
• An afdavit of employment listing each job held during the lapsed licensure period. This
afdavit of employment must include the names, addresses and telephone numbers of each
employer;
• A notarized statement indicating if you were or were not engaged in the practice of Orthotics or
Prosthetics in New Jersey during the period that your New Jersey license was lapsed. If you
were practicing as Orthotist or Prosthetist during this lapsed license period, you must include
a description of the type of work or projects that you were involved with;
• Completion of Criminal History Background Check. See enclosed instructions and form to
be completed.
• A certication verifying completion of the continuing education credits required pursuant to
N.J.A.C. 13:44H-6.3 for a renewal of a license.
.
3. Submit to: Division of Consumer Affairs
Orthotics and Prosthetics Board of Examiners
PO Box 45034
Newark, NJ 07101
Upon review and approval of your reinstatement application, a license will be issued.
New Jersey Ofce of the Attorney General
Orthotics and Prosthetics Board of Examiners
124 Halsey Street, 6th Floor, P.O. Box 45034
Newark, New Jersey 07101
(973) 504-6445
Application for Reinstatement of New Jersey License
You may not practice in the State of New Jersey until your license or certicate is reinstated.
Date: ________________________________
A nonrefundable reinstatement fee (see instructions page) in the form of a check or money order made out to the State of New Jersey,
must be submitted with this application. (Applicants should understand that if the fees are paid with a personal check, and the check is
returned by the bank due to insufcient funds, the next step in the reinstatement process will be delayed until the fees are paid.)
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _________________________
Month Day Year
Place of birth: ________________________
City State
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: ______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Business: ____________________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
For Ofce Use Only
Initial date received:
_________________________
Initial applicant I.D. number:
_________________________
Initial license number:
_________________________
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months.
A photo is required with each
application.
Do not use staples to attach the
photo.
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*Social Security Number: __________ -____________ - ___________
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7, 60.8 and 60.9, the Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
5. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of licensure or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
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6. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
7. Have you ever been convicted of any criminal offense? (Minor trafc offenses such as parking or speeding violations need not be
listed; however, motor vehicle offenses such as driving while impaired or intoxicated must be disclosed.) Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a
complete
explanation. (Attach additional sheets of paper to this application.)
8. Do you currently hold, or have you ever held, a professional license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please provide that name. ____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
9. Have you ever been disciplined or denied a license or certicate as an orthotist assistant, prosthetist assistant or a prosthetist-orthotist
assistant or any other professional license or certicate in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
10. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other state,
the District of Columbia or in any other jurisdiction? Yes No
11. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any
agency or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
12. Have you ever been named as a defendant in any litigation related to the practice of orthotics or prosthetics or other professional
practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
13. Are you aware of any investigation pending against a professional license or certicate issued to you by any professional board in
New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
14. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
15. Have you ever been sanctioned by, or is any action pending before, any employer, association, society, or other professional group
related to the practice of orthotics or prosthetics or other professional practice in New Jersey, any other state, the District of Columbia
or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 9 through 15, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
Afx Seal Here
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of: ___________________________________________
I, ___________________________________________ , in making this application to the Orthotics and Prosthetics Board of
Examiners for licensure under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the Orthotics
and Prosthetics Board of Examiners, swear (or afrm) that I am the applicant and that all information provided in connection
with this application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure
to make full disclosures may be deemed sufcient to deny licensure or to withhold renewal of or suspend or revoke a license
issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:12B-1 et seq., together with the Rules and Regulations of the Orthot-
ics and Prosthetics Board of Examiners, N.J.A.C. 13:44H, and fully understand that in receiving licensure from the Board,
I bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
the purpose of verifying my qualications for licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board.
_____________________________________________
Applicant’s signature
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
} ss.
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Orthotics and Prosthetics Board of Examiners
P.O. Box 45034
Newark, New Jersey 07101
(973) 504-6445
CertifiCAtion And AuthorizAtion form
f
or A CriminAl history BACkground CheCk
Directions: Answer all of the questions on this form.
1. Name _________________________________________________________ ( ________________________)
Last First Middle Maiden Name
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
Month Day Year
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs since November 2003?
Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history record background
check process. No payment is necessary as of now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certification by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background
check conducted for the Department of Education, another state agency or another state does not apply) you will not be
required to be ngerprinted a second time. However, the Division must perform a criminal history background check each time
you apply for licensure or certication. The fee for this service is $18.75. Payment should be made in the form of a check or
money order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor trafc offenses such as a parking or speeding
violations need not be listed.)
Yes No
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within ve (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Mr.
Mrs.
Ms.
Board or Committee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
Dual License
License Type 1
________________________
Applicant’s Number
________________________
License Type 2
________________________
Applicant’s Number
________________________
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufcient to deny certication or licensure or to withhold renewal of or suspend or revoke a certicate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________ _________________________________
Signature of applicant Date
Rev. 1/2/19
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Orthotics and Prosthetics Board of Examiners
124 Halsey Street, 6th Floor, P.O. Box 45034
Newark, New Jersey 07101
(973) 504-6445
Afdavit of Employment for the Reinstatement of a Lapsed License
Directions: Please complete this afdavit of employment, sign and date it and return it to the
Orthotics and Prosthetics Board of Examiners. If you have had more than two employers, please
add additional sheets of paper with the employment data. The Board may contact your employer(s)
to verify your employment.
______________________________________________________________________________
First name Middle name Last name Maiden name
______________________________________________________________________________
Present Street Address City State ZIP Code
Employment Data:
1. ___________________________________________________________________________
Name of employing agency or facility
___________________________________________________________________________
Street address
___________________________________________________________________________
City State ZIP Code
___________________________________________________________________________
Job Title Employment Dates: From To
___________________________________________________________________________
Supervisor’s name Title Telephone No. (include area code)
2. ___________________________________________________________________________
Name of employing agency or facility
___________________________________________________________________________
Street address
___________________________________________________________________________
City State ZIP Code
___________________________________________________________________________
Job Title Employment Dates: From To
___________________________________________________________________________
Supervisor’s name Title Telephone No. (include area code)
______________________________ ______________________________ ____________________
Applicant’s name (Please print) Applicant’s signature Date
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Instructions for Reinstating New Jersey Ofce of the (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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